Jaeger v. Bureau of Workers' Compensation Fee Review Hearing Office
24 A.3d 1097
| Pa. Commw. Ct. | 2011Background
- Jaeger, M.D. provided 40 VAX-D treatments to Adame between May 30 and July 18, 2007 and billed CNA using Medicare code 97799.
- CNA downcoded the VAX-D treatments to code 97012, arguing the latter better describes the procedure.
- CNA sent ten-day notice letters explaining the downcoding and provided an opportunity to dispute within ten days; revised EORs followed if no timely response.
- CNA paid non-VAX-D charges during the ten-day window, but did not adjust downcoded VAX-D payments until after the period expired.
- The Bureau initially ruled for Jaeger, awarding additional fees; CNA sought a de novo hearing, which CNA prevailed, leading to an order reversing the Bureau and denying Jaeger any further VAX-D reimbursement.
- The court affirmed the Hearing Officer’s reversal, holding CNA complied with 34 Pa.Code § 127.207 and that Jaeger was not owed additional VAX-D fees.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether CNA complied with 34 Pa.Code § 127.207 downcoding requirements | Jaeger contends CNA failed to prove notice or proper procedure | CNA asserts proper ten-day notice, discussion opportunity, and evidence of notice | Yes, CNA complied and the downcoding was proper |
| Whether ten-day notices were properly proven | Jaeger argues notices were not proven or delivered | CNA introduced dated ten-day notices as business records | Yes, notices proven by records; able to infer notice sent |
| Whether payments during the ten-day period affected compliance | Jaeger argues payments during the ten days nullified compliance | Payments during ten days were for non-VAX-D charges; downcoded VAX-D payments occurred later | No, compliance unaffected; ten-day period respected |
| Whether ten-day notices and related records are admissible in fee-review hearing | Jaeger contends notices are hearsay or unsigned | Records fall under business records exception; not required to prove personal drafting | Yes, admissible as business records under PA Rule of Evidence 803(6) |
| What is the standard of review and burden in fee review | Jaeger challenges the Hearing Officer's findings | Hearing officer credibility and findings not to be reweighed by appellate court | Hearing Officer's findings supported by substantial evidence; de novo standard applied |
Key Cases Cited
- Pittsburgh Mercy Health System v. Bureau of Workers' Compensation, Fee Review Hearing Office, 980 A.2d 181 (Pa.Cmwlth.2009) (scope of review and deference to hearing officer findings)
- Harburg Medical Sales Co. v. Bureau of Workers' Compensation (Employers Mutual Casualty Co.), 911 A.2d 214 (Pa.Cmwlth.2006) (credibility and evidentiary standards in fee review)
- Department of Labor and Industry v. Unemployment Compensation Board of Review, 2 A.3d 1292 (Pa.Cmwlth.2010) (business records exception applied to documentary evidence in fee review)
- Allen v. Bureau of Workers' Compensation Fee Review Hearing Office (Kemper Insurance), 852 A.2d 415 (Pa.Cmwlth.2004) (explains downcoding regulations and administrative procedures)